Interactive association of chronic illness and food insecurity with emergency department utilization among school‐age children in the United States: A cross‐sectional study

Abstract Background and Aims Food insecurity combined with chronic disease conditions is a risk factor for Emergency Department (ED) utilization, an indicator of poor quality of care. However, such an association is not certain among school‐age children with chronic conditions. Therefore, we aim to determine the association of food insecurity, chronic conditions, and ED utilization among school‐age children in the United States. Methods We analyzed the data from the 2017 Medical expenditure panel survey (MEPS) among children aged 6–17 years (N = 5518). MEPS data was released electronically by the Agency for Healthcare Research and Quality (AHRQ). We identified four groups of school‐age children based on the presence of food security and chronic conditions: 1) with food insecurity and chronic conditions; 2) no food insecurity and chronic conditions; 3) with food insecurity and no chronic conditions; and 4) no food insecurity and no chronic conditions. We compared ED utilization among these four groups using incidence rate ratios (IRR) after adjusting children's age, sex, race and ethnicity, household income, insurance coverage, obesity, and geographic region using count data model, specifically multivariable Poison regression. We used SAS 9.4 and STATA 14.2 for all the data analyses. Results There were unweighted 5518 school‐age children who represented weighted 50,479,419 school‐age children in the final analysis. Overall, 6.0% had food insecurity with chronic conditions. These children had higher ED utilization (19.7%) than the other three groups (13.3%, 8.8%, and 7.2%, p < 0.001). The adjusted IRR of ED utilization among school‐age children with food insecurity and chronic conditions was 1.90 (95% confidence interval 1.20–3.01, p = 0.007) compared with those with food security and chronic conditions. Conclusion One in 16 school‐age children has both food insecurity and chronic conditions. Food insecurity was positively associated with frequent ED visits in the presence of chronic conditions. Therefore, addressing food insecurity may reduce the risk of ED visits.

presence of chronic conditions. Therefore, addressing food insecurity may reduce the risk of ED visits.

K E Y W O R D S
chronic conditions, ED utilization, food insecurity, MEPS, school-age population 1 | INTRODUCTION Food insecurity is defined as "inability to acquire adequate food for one or more household members because they had insufficient money and other resources for food." 1 In 2020, 7.6% (2.9 million) households in the United States with children reported food insecurity. The prevalence of food insecurity in households with children increased in 2020 to 14.8% from 13.6% in 2019. 1 In addition, there are disparities in the prevalence of food insecurity by race and ethnicity, disability status, and urbanicity. 2 Studies have demonstrated that children living in households with food insecurity are at risk for poor physical, emotional, and developmental outcomes. [3][4][5] There is robust evidence of the positive relationship of food insecurity with adverse health outcomes. 6 Food insecurity can lead to high healthcare utilization including preventable hospitalizations, 7 emergency department (ED) visits, 8 and high healthcare costs. [9][10][11] Using 2016 data from the Medical Expenditure Panel Survey (MEPS), which contained information about sociodemographics, health needs, healthcare service uses, and healthcare cost, authors found that children living in households with food insecurity were more likely to have ED use. 12 However, this study did not analyze the interactive association of chronic conditions and food insecurity linked to ED utilization. It is essential to examine ED visits because such visits are costly 13 and may represent poor management of chronic conditions, 14 poor quality of care, 15 lack of access to emergent care, 14 and maybe preventable with appropriate primary care. 16 Food insecurity is reported to be common in pediatric EDs. 17,18 In a study of 4674 children seen at a general pediatric clinic between 2017 and 2021, food insecurity was reported to be associated with increased ED utilization and hospitalizations. 19 However, these studies were conducted only among those who visited ED. Given that children with chronic conditions are more likely to use ED than those without chronic conditions, 20 examining the excess burden of food insecurity on ED use among children with chronic conditions is important. However, such studies are sparse.
Determining such an association between food insecurity, chronic disease conditions, and ED utilization among pediatric populations could serve as a foundation to assist families in obtaining services to prevent food insecurity, improve healthcare outcomes, and eventually reduce healthcare costs. Therefore, the primary objective of this paper was to determine the interactive association of chronic illness and food insecurity with ED utilization among school-age children using well-established and validated nationally representative survey data in the United States of America.

| Study design and data source
This study adopted a cross-sectional study design. Data were obtained from the 2017 MEPS (i.e., full-year consolidated data, medical condition data, released on March 4, 2020). MEPS is a nationally representative survey of noninstitutionalized civilian households administered by the Agency for Healthcare Research and Quality (AHRQ). The survey collects information on healthcare services utilization and costs, demographic characteristics, social determinants of health (SDoH, such as education, employment, and income of households), and health status. Food security information was collected in a separate module in 2017. We limited our study to data collected in the calendar year 2017. As MEPS is a publicly available data set with deidentified data, this study was submitted to regional institution review board and approved as a nonhuman subject research project.

| Participants
The study included school-age children 6-17 years of age (N = 5691).
Among these children, 173 did not have data on food insecurity. The final study sample included 5518 (2809 males with weighted 51.2% and 2709 females with weighted 48.8%) children that represented 50,479,419 children aged from 6 to 17 years.

| Primary outcome measurement
Our primary outcome was the number of ED visits reported for the survey year. The number of ED visits ranged from 0 to 9 in our analytic sample. The MEPS household file contains utilization and expenditure data from the household self-reports and the medical providers. The medical provider component (MPC) data are not publicly available and are used for editing and imputing household file data. 21 MPC data include ED visits that may or may not have resulted in an inpatient stay. 22

| Key Explanatory Variable
Food insecurity and chronic condition categories.

Presence of chronic conditions (yes/no)
In the MEPS, chronic conditions can be derived from several sources, such as directly asking the respondents whether they have been diagnosed with certain priority conditions, conditions for which the respondents sought medical care, conditions that caused the participants to miss school or work or spend more than half a day in bed. 23 We used the questions of whether the child has ever been diagnosed with asthma, the conditions for medical care were sought (diabetes, bronchitis, anxiety, depression, and bipolar disorders).
Children with any of the conditions mentioned above were considered to have chronic conditions.

Food insecurity
MEPS special module includes specific questions about food security that are closely aligned with the United States Department of Agriculture (USDA) 10-item scale. 24 However, the USDA 10-item scale queried food security in the previous 12 months, MEPS-specific questions reference period is "previous 30 days." Following the methodology provided by Dean et al., 25 we adjusted the scale for reference-period differences. The food security questions inquire about accessing adequate food, reduced quantity, and quality of food consumption. Households that worried about food availability, households with limited food intake due to affordability, households without adequate food, and households that experienced disrupted eating were classified as having "food insecurity." We combined the presence of chronic conditions and food insecurity to derive four categories: 1) with food insecurity and chronic conditions; 2) no food insecurity and chronic conditions; 3) with food insecurity and no chronic conditions; and 4) no food insecurity and no chronic conditions.
Children's body mass index (BMI) was divided into four categories underweight, normal, overweight, and obese. These categories were determined using CDC age-and sex-specific growth charts for children and teens ages 2-19. 26 We included household income relative to the federal poverty line (poor, low-, middle-, and highincome), and insurance coverage (private, public, and no insurance).

| Statistical analysis
The analyses accounted for the complex design of the MEPS by using survey procedures with family weights. Rao-Scott chi-square test of independence was used to assess whether food insecurity and chronic conditions (Group 1: food insecurity with chronic conditions; Group 2: food security with chronic conditions; Group 3: food insecurity without chronic conditions; and Group 4: food security without chronic conditions) were associated with ED utilization. We calculated unadjusted and adjusted incident rate ratios (IRR) and corresponding 95% confidence intervals (CI) using Poisson regression to determine the association between food insecurity with a chronic condition and the number of ED visits. The adjustment included children's age, sex, race and ethnicity, poverty status, health insurance, and geographical location to further determine the potential confounders. These analyses were performed in SAS 9. The unadjusted IRR (U-IRR) and 95% CIs from the Poisson regression of ED visits are summarized in Table 2. The unadjusted IRRs were higher for those with food insecurity and chronic conditions compared to those without food insecurity and chronic conditions (IRR = 1.99, 95% CI = 1.28-3.10 p < 0.001). In general, those without chronic conditions had fewer ED visits than those with chronic conditions (Table 2).
When adjusted for other explanatory variables, age, sex, race and ethnicity, household poverty status, health insurance, region, and child BMI, the adjusted IRR was higher for children with chronic conditions and living in households with food insecurity (IRR = 1.90, 95% CI 1.20-3.01, p = 0.007). Consistent with unadjusted associations, children with no chronic conditions (with or without food insecurity) had fewer ED visits (Table 3).  (Table 1). These study findings are similar to the previous reports by Peltz and Garg. In their report, it showed that food insecurity was associated with race and ethnicity (i.e., higher food insecurity rate among African Americans and Hispanics), T A B L E 1 Characteristics of school-age children by food insecurity and chronic condition groups. T A B L E 2 Unadjusted incident rate ratio (U-IRR) and 95% confidence intervals (CI). T A B L E 3 Adjusted incident rate ratios (A-IRR) and 95% confidence intervals (CI). geographic location (i.e., Mid-west), and low-income household (e.g., single-parent home and publicly insured children (compared with privately insured ones), parents unemployed), and so forth. 12 Other studies also showed that food insecurity was associated with poverty (e.g., annual household income), 1,27 children of color (e.g., African Americans and Hispanics), and children with obesity. 1,28,29 It is not surprising to find an association between food insecurity and obesity among children. 30 Studies have found that those with food insecurity consume fewer fruits, vegetables, and protein-rich diets 31,32 and rely more on a high-calorie unhealthy diet, 33 which may lead to obesity.
We also observed that children who had chronic conditions and lived in households with food insecurity had higher ED visits compared to children with chronic conditions and no food insecurity ( Our study has strengths and limitations. We used nationally representative data with a validated food insecurity measure, which enabled us to provide insights into the needs of a specific population subgroup and potential policy interests. The results are generalizable because the data cover diverse segments of the noninstitutionalized civilian population. However, we adopted a cross-sectional design and can only report associations. In terms of school-age children with chronic conditions, bronchitis and anxiety certainly could present as acute disease conditions. However, MEPS did not specify chronic bronchitis or anxiety which could result in overestimations of chronic conditions in our study. Furthermore, we did not account for the bidirectional relationship between food insecurity and ED use. 39 The foodinsecurity measure was based on the household, and we could not assess child-specific insecurity. We also did not explore whether food-insecure families received public assistance programs such as the Supplemental Nutrition Assistance Program (SNAP). Chronic conditions data may be incomplete because some chronic conditions were captured if they were reported as a general problem, sought medical care, missed school days, or days spent in bed. 23

| CONCLUSION
One in 16 (6.0%) school-age children had chronic conditions and lived in households with food insecurity. Among all school-age children with chronic conditions, children with food insecurity had 1.9 times higher ED utilization than those without food insecurity. Our findings suggest that ED visits might be leveraged to screen children at highrisk for food insecurity.

Dr. Hao Wang is an Editorial Board member of Health Science
Reports and a coauthor of this article. To minimize bias, he was excluded from all editorial decision-making related to the acceptance of this article for publication.